June 4, 1999
Diagnosis and Symptoms, Hyperglycemia and DKA
Question from the United Kingdom:
My 4 year old daughter has been unwell for a few weeks and was recently diagnosed with a UTI (urinary tract infection), and treated with a full course of antibiotics. She had normal urinalysis last week, so I did not embark on a second course. However, she continues to wet the bed at least twice a night (from being dry previously) and is off colour generally. I am a doctor myself, but not experienced in paediatrics (I am in research in neurology). As there is a family history of diabetes (maternal grandmother) and my daughter had Coxsackie B meningitis as a baby, I have been concerned that she is at risk of diabetes. I have noticed that her moods fluctuate markedly according to when she eats. Today, she again complained of a headache on rising at 8, and seemed a little unwell, with a mild fever of 37.5C. She ate 2 oranges, some cereal and milk, drank some juice. Between 9 and 10 she ate 2 pieces of toast with butter and jam. At 10.30 I did a Uristix on her urine to check if there were signs of the UTI recurring and found she had +++ of ketones. This was repeated by the GP, who has suggested a fasting blood glucose in a week’s time. Later (midday) I repeated her urinalysis and it was normal.
Do you think that an overnight fast (and mild fever) could account for the ketonuria, or do you think I should get her checked out before the appointment next week. She has not been vomiting or had diarrhoea, but has complained of abdominal pains. Apart from looking pale, she seems OK.
I apologise if this is inappropriate for this site, but to be honest, I do not feel my own clinical experience sufficient and I regret to say I do not have total confidence in my GP. I am mostly concerned because of the factors such as Coxsackie B, the family history and infection, and would much prefer to get an early diagnosis (or exclude it) rather than let my daughter get into an acute situation. Obviously I am not asking for a diagnosis, merely some indication in broad terms as to whether I should seek further medical attention now or leave it till a week’s time.
Answer:
You don’t give us the crucial piece of information which was whether your daughter showed any glucose in her urine especially when she had the ketones. Assuming that there was no glucosuria, then what would concern me about the story you give is that the UTI was not fully cleared up and that there is a continuing subclinical infection. This can be resolved by taking a clean catch specimen and getting the lab to do a culture or better still a colony count. Admittedly first UTI’s in girls tend to be rather dismissed; but with this story I would want to be very sure it had not lingered. She might even need a period of prophylactic antibiotics.
The ketones could certainly explained in a little girl who was not very well and had a diminished appetite especially if the specimen was in some measure an overnight one.
If there was indeed no evidence of glucosuria I think it very unlikely that the problem is diabetes ; but if you are anxious you should ask to have an antibody test done, (anti insulin, anti-glutamic acid decarboxylase, anti-islet cell 512, and with luck anti-transglutaminase and anti-21-hydroxylase antibodies). You may have to talk to the nearest paediatric endocrinologist about where to get this done in the UK.
Current thinking rather discounts Coxsackie infections as being linked to Type 1A diabetes even though it is autoimmune like MS!
DOB
